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Medicare and Medicaid: What are they and how can they help me pay for care?

Medicare

Medicare is a health coverage program provided by the federal government. It is divided into four parts, and most U. S. citizens age 65 and over are eligible for it, as are some people under 65 who are disabled, and people at any age with end-stage renal disease.

MedicarePart A provides hospital, hospice and limited home health care coverage. It is free to eligible citizens 65 and older who, either themselves or their spouse, have paid Medicare taxes for 40 or more quarters. Anyone who already receives or is eligible to receive Social Security or Railroad benefits but hasn't yet filed for them, is eligible for Part A. Other citizens or lawfully admitted aliens who have lived in the U.S. for at least five years can pay a monthly premium.

Medicare Part B, administered by the government, covers medically necessary doctor visits, out-patient services, lab tests, x-rays, rehabilitation and physical therapy services, and medically necessary medical equipment. Under this plan, you can go to any doctor you choose. The current monthly premium for people earning $82,000 or less per year is $96.40 and there is an additional co-pay of 20 percent of the cost of the services covered. (Monthly premiums go up to $238.40 for those earning above $205,000 a year.) Eligible seniors can sign up for Part B within a 7-month period that begins 3 months before they turn 65. You can enroll by calling Social Security at 1-800-772-1213 or visiting or calling your local Social Security office.

Medicare Part C is the Medicare Advantage Plan — an optional plan administered by private insurance plans and substitutes for coverage under Part A and B. This plan is less costly than Part B, but because it restricts one's choice of doctors and service providers, it is important to be sure that the service providers covered are accessible and meet your needs.

Medicare Part D is an optional prescription drug coverage plan. There are many choices of plans, and they each have different monthly fees, yearly deductibles, and co-pays. In addition, all plans fit into a complex system under which after a certain amount of coverage, there is a gap in coverage up until another level is reached. Different plans cover different medications, so you need to check each plan to see which one covers the medications you are currently taking. At a certain time each year you can switch plans in case your medication needs change or you are unhappy with your current plan. For more information about the different options, go to formulary finder.

Jody Gastfriend, vice president of senior care at Care.com, describes what Medicare covers for rehab in her book My Father's Keeper: "If your parents are sixty-five years or older and are U.S. citizens, they probably have Medicare. If they end up qualifying for rehabilitation after a hospital stay, Medicare will pay for up to one hundred days of skilled care in a skilled nursing facility (also known as a SNF — pronounced snif ). These rehab stays often take place in actual nursing homes, which are geared for people who need a slower pace, like my father.

But don’t get confused. If your father no longer has a need for daily skilled help — time’s up, whether he’s been there for a hundred days or not. To be eligible for rehab under Medicare, patients must have a need for skilled care — nursing, physical therapy, speech therapy, or occupational therapy. They must demonstrate the capacity for improvement or the likelihood that skilled care will prevent further deterioration. If these conditions aren’t met, Medicare coverage may end."

In addition, you can purchase a Medigap policy, which helps cover the cost of gaps in coverage, such co-pays and deductibles. You would pay an additional monthly fee for this Medigap coverage.

Medicaid

Many people confuse Medicare and Medicaid. Medicaid is a plan offering health coverage to low-income residents who meet specific federal and state criteria. These criteria vary from state to state and are based on income, assets and resources. The cost of this coverage is either free or much less expensive than Medicare Plan B or C.

Medicaid covers medical care such as physician visits, hospital bills, prescriptions and long term care. It is the largest payer source of long term care and covers two-thirds of all nursing home patients. Medicaid does vary by state and every state has different eligibility requirements for each population that they serve: pregnant women, children, the elderly or disabled individuals. To determine eligibility you must fall within the income level determined by the state.

If you or a loved one may be eligible for Medicaid you can contact an elder law attorney for more information about eligibility in your state.

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